Originally Posted on Psychology Today

When it comes to veterans and mental health, I’m usually one of the first, and loudest, to argue that it’s often not PTSD. Studies of veterans deployed in the recent conflicts in Afghanistan and Iraq estimate the range of PTSD prevalence between 4.7% and 19.9%. However, the upper-limit of these estimates is likely exaggerated due to variability in the quality of the studies. Studies employing methodologically rigorous design elements consistently document PTSD rates under 10%. That is still not a small number but it’s also not nearly as pervasive as most believe.

Official USMC photo, Staff Sgt. Jeremy Ross, released for public domain
Marines with Bravo Battery, 1st Battalion, 10th Marines, Regimental Combat Team 8, patrol through a poppy field in the Kajaki green zone, Helmand province, Afghanistan
Source: Official USMC photo, Staff Sgt. Jeremy Ross, released for public domain

If you take a moment to think about this, it makes evolutionary and biological sense.  Human beings’ resilient nature is what has allowed our species to survive and thrive. If we decompensated every time we encountered something threatening, we’d never make it through a day — let alone 200,000 years. We should be thrilled that our most common response to trauma is resilience. Instead, there appears to be a desire to over-diagnose, call attention to, and sensationalize the ‘broken warrior(link is external).’ Just Google “damaged veteran stereotype.”(link is external)

Make no mistake, this is not to call into question the insidiousness and presence of PTSD, or to stigmatize those who do have it. PTSD is devastating and it is tortuous if left untreated or is treatment resistant. It takes great strength, fortitude, and courage to battle your mind day in and day out and even the strongest struggle.

Chronic and severe PTSD have measurable physiological states and neurological consequences. Yet, we still don’t know, with certainty, why some people develop it and others don’t. While no biomarkers have been identified, there are some indications that it might be related to baseline hippocampal volume (the brain region associated with memory). This has led some researchers to hypothesis that PTSD is more akin to a memory disorder. They argue that suboptimal hippocampal activity during the trauma may lead to decontextualized memories. These memories, isolated from context, lead to distortion and confused sensory impressions about the trauma event itself and it subsequently cannot be consolidated appropriately in autobiographical memory.

That doesn’t even begin to address the other range of variables that are at play, such as personality factors, cognitive variables, hormones (i.e. glucocorticoids), epigenetics, and/or trauma characteristics. Whichever way you slice it, regardless of the cause, PTSD can cause significant departure from functional baseline.

As such, clinical standards require impairment for at least one month before PTSD can be diagnosed because experiencing nightmares, flashbacks, heightened startle response, and hypervigilance is entirely normal immediately following trauma. It’s continuation past that point and accompanying life impairment that is atypical.

If such criteria are met, we must acknowledge it for what it is. A disorder. In normalizing the use of PTS (post-traumatic stress) in lieu of PTSD, we inadvertently communicate that treatment is not necessary. Calling PTSD for what it is, is essential. Not because I, or anyone, desires to shame the suffering but because it signifies the terrible nature of the syndrome and then holds us accountable to that seriousness.

Oversaturation of PTSD in the trauma conversation does a disservice to those who experience the full magnitude of its manifestation and obscures the complexity of the military and veteran experience. The issue should not be with what we call it but with how we react to its presence.

What’s worse, in the widespread application of PTSD we assume the forest for the trees. For those who present for mental health treatment, we fail them by presuming that their military service and combat exposure are the crux of the presenting issue. In fact, levels of combat exposure do not predict the development of PTSD.

Relatedly, many Veterans who do participate in evidence-based, gold standard treatments for PTSD (i.e. cognitive processing therapy (CPT) and prolonged exposure (PE) therapy) continue to suffer elevated symptom levels with extremely high dropout rates. This suggests:

1. An urgent need for new types of interventions and supports

And/or

2. It’s not PTSD

The latter is particularly significant because, if true, it means we are missing something. This something is causing suffering and is potentially far more ubiquitous, pervasive, and likely unrelated to trauma. There is a clear need for greater study and understanding of the heterogeneity in veteran mental health outcomes.

This is not the only place we, as a military/veteran population and society, are getting it wrong. We have inadvertently elevated the PTSD diagnosis. In the military and veteran population there are some who believe that if you carry the diagnosis, it means you’ve truly served and seen combat.  In the mental health sector (and maybe, writ large), focusing on and diagnosing PTSD is the lesser of two evils. It’s better to diagnosis than not, to ensure benefits are conferred and to protect yourself as the provider. If we move past the surface, what we find is this way of taking care of those worthy of care is, in fact, careless.

Moreover, there are some substantial problems in the widespread application of this philosophy.  First and foremost, the VA currently does not mandate treatment.  Meaning, a veteran can be rated at a high level of disability, receive the associated benefits, and never commit to attempting to improve their functioning. This disempowers veterans, incentivizes continued reliance on government assistance, and holds no one accountable. Veterans are at their best when they are viewed as an asset, not as a burden.

The failure to appreciate the collective complexity of the military and veteran experience, in addition to the caustic influence of PTSD and TBI, only perpetuates the misunderstanding and ongoing stagnation surrounding current veteran treatment. There is no one size fits all. It will only be when the heterogeneous difficulties are better understood that we will be able to develop a repertoire of interventions to target relevant symptomatology and protect against deleterious areas of military service. Until then, we must continue to ask hard questions, confront perpetuating stereotypes, and find ways to empower, not entitle.

 

 

References

Berntsen, D., Johannessen, K. B., Thomsen, Y. D., Bertelsen, M., Hoyle, R. H., & Rubin, D. C. (2012). Peace and war: Trajectories of posttraumatic stress disorder symptoms before, during, and after military deployment in Afghanistan. Psychological science, 23(12), 1557-1565.

Bonanno G.A., Mancini A.D., Horton J.L., Powell T.M., Leard Mann C.A., Boyko E.J., Wells T.S,. Hooper T.I., Gackstetter G.D., Smith T.C.. (2012). Trajectories of trauma symptoms and resilience in deployed US military service members: Prospective cohort study. The British Journal of Psychiatry; 200(4):317-23.

Donoho, C. J., Bonanno, G. A., Kearney, L., Porter, B. & Powell. T. (2017). A Decade of War: Prospective Trajectories of Post-Traumatic Stress Disorder Symptoms Among Deployed US Military Personnel and the Influence of Combat Exposure. American Journal of Epidemiology.

Gilbertson, M. W., Shenton, M. E., Ciszewski, A., Kasai, K., Lasko, N. B., Orr, S. P., & Pitman, R. K. (2002). Smaller hippocampal volume predicts pathologic vulnerability to psychological trauma. Nature neuroscience, 5(11), 1242.

Magruder KM, Yeager DE. (2009). The prevalence of PTSD across war eras and the effect of deployment on PTSD: a systematic review and metaanalysis. Psychiatr Ann; 39(8):778-88.

McNally, R. J. (2012). Are we winning the war against posttraumatic stress disorder?. Science, 336(6083), 872-874.

Mobbs, M. C., & Bonanno, G. A. (2017). Beyond war and PTSD: The crucial role of transition stress in the lives of military veterans. Clinical psychology review.

Rauch, S. A. M., Eftekhari, A., & Ruzek, J. (2012). Review of exposure therapy: A gold standard for PTSD treatment. Journal of Rehabilitation Research and Development, 49, 679–688. http://dx.doi.org/ 10.1682/JRRD.2011.08.0152

Shin, L. M., Rauch, S. L., & Pitman, R. K. (2006). Amygdala, medial prefrontal cortex, and hippocampal function in PTSD. Annals of the New York Academy of Sciences, 1071(1), 67-79.

Steenkamp  MM, Litz  BT, Hoge  CW, Marmar  CR. (2015)  Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA;314(5):489-500.

Steenkamp, M. M., & Litz, B. T. (2013). Psychotherapy for military-related posttraumatic stress disorder: Review of the evidence. Clinical psychology review, 33(1), 45-53.

Steenkamp, M. M. (2016). Treatment Options for Veterans With Posttraumatic Stress Disorder-Reply. JAMA psychiatry ;73(7):757-758.

Steenkamp, M. M., Litz, B. T., Gray, M. J., Lebowitz, L., Nash, W., Conoscenti, L., Amidon, A., & Lang, A. (2011). A brief exposure-based intervention for service members with PTSD. Cognitive and Behavioral Practice, 18, 98–107. http://dx.doi.org/10.1016/j.cbpra.2009.08.006(link is external).

Steenkamp, M. M. (2016) True Evidence-Based Care for Posttraumatic Stress Disorder in Military Personnel and Veterans. JAMA psychiatry; 73(5):431-432.

 

Meaghan Mobbs, M.A. is a West Point graduate, Afghanistan Veteran, and former Army Captain who is currently an advanced Clinical Psychology doctoral student at Columbia University, Teachers College.  Mobbs is also a David O’Connor Fellow, Tillman Military Scholar, and a Noble Argus and National Military Family Association Scholarship recipient.